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ODRP 726 Patient Diagnosis and Treatment Planning Objective is to rehabilitate the patient’s oral condition Includes procedures to improve function and appearance ◦ ◦ ◦ ◦ ◦ ◦ Perio surgery Ortho treatment Occlusal therapy Elective oral surgery Replacement of missing teeth Cosmetic or esthetic procedures Follows initial treatment (root planing) May be indicated for residual diseased sites ◦ Surgical flaps to improve access and increase visibility Close furcation – bone graft Make furcation easier to clean – apical repositioning Improve placement of crown margin Reduce pocket depth Increase biologic width Thorough scaling and root planing, and OHI Re-evaluate Gingivectomy – blade, laser, electrosurgery Healthy lifestyle ◦ Good nutrition ◦ Good control of systemic disease Use of tobacco products Patient motivation for treatment Willingness to follow through with treatment Comprehensive orthodontics Limited orthodontic movement ◦ Forced eruption – compromised biologic width ◦ Molar uprighting ◦ Minor tooth movement – 6 or fewer teeth Orthognathic surgery Indications ◦ ◦ ◦ ◦ ◦ ◦ ◦ Severe attrition Abnormal occlusal planes Malposed teeth Occlusion-related periodontal attachment loss Parafunctional habits Temporomandibular disorders Participates in contact sports Selective grinding of teeth Often an adjunctive therapy to ◦ alleviate symptoms of temporomandibular dysfunction ◦ Complement comprehensive prosthodontic reconstruction Treatment goals ◦ Develop and acceptable centric relation contact position ◦ Provide for acceptable lateral and protrusive guidance ◦ Establish an acceptable plane of occlusion with adequate interarch space to replace teeth Bite guard, bite splint, occlusal guard, night guard Indications ◦ Symptoms of TMD – provides a more orthopedically stable TMJ position reorganizes the neuromuscular reflex activity Relieves pain Confirm diagnosis of TMD ◦ Prevent tooth wear caused by bruxism ◦ Assess the patient’s tolerance of increased vertical dimension of occlusion Reversible and non-invasive Protect remaining tooth structure After placement of large restorations (core build-up) ◦ Caries control ◦ Fractures ◦ Replacement of large restoration Restoration after root canal treatment Gold or porcelain inlay Intracoronal restoration Used instead of amalgam or composite Increased longevity Covers one or more cusps of posterior tooth to strengthen remaining tooth Onlay, MOD onlay, ¾ gold crown, 7/8 gold crown, inlay-onlay Can be gold or ceramic Used to preserve unaffected tooth structure Full gold ◦ Best against natural teeth and gold ◦ Best longevity ◦ No likelihood of fracture PFM All-ceramic ◦ Best strength ◦ Esthetic ◦ Best esthetics ◦ Least strength ◦ Can be one-appointment Studies show decreased fracture resistance with cast post Cast post has added expense and added appointment Indications ◦ Multiple post and core restorations planned on the same arch ◦ Smaller teeth (mandibular incisor) prefab posts difficult to fit ◦ If the angle of the core relative to the tooth must be changed How much tooth structure remains? Horizontal forces applied No existing restorations (except access prep) Less than 50% of crown is missing More than 50% of crown missing ◦ ◦ ◦ ◦ Fracture resistance = normal tooth Access cavity restored with composite No post required May require bleaching as tooth discolors ◦ No post required ◦ Porcelain veneer (covering incisal edge and facial) ◦ Prepare tooth to determine if post is necessary Based on remaining resistance form ◦ Full crown is required Vertical forces Fracture resistance decreases as amount of dentin removed increases Post is only recommended when more conservative retention and resistance features are not possible Amalcore is effective ◦ Amalgam placed in the entire pulp chamber area and in the coronal 2.0 – 3.0 mm of each canal. Threaded pins Adhesive materials Post should be used if the tooth is to be used as an abutment for an RPD – increased horizontal forces – when placing and removing RPD Post should be used if there is inadequate pulp chamber for retention of core Posts are placed only in: ◦ Palatal canal for maxillary molars ◦ Distal canal for mandibular molars Never more than one post is required Posts NEVER strengthen a tooth Posts improve retention of crown Microabrasion ◦ Superficial stain removal ◦ Defective surface material is removed using abrasion/erosion ◦ Bathed in fluoride gel Contouring teeth ◦ Minor alterations from fractured, chipped, extruded or overlapped teeth ◦ Rotary instruments used to remove and polish teeth ◦ Contraindications – hypersensitive teeth, thin enamel Vital bleaching ◦ Toothpaste and OTC bleaching strips ◦ Bleaching At-home bleaching – 4-6 weeks In-office – immediate results Pulpal sensitivity Bleaching devitalized teeth ◦ Endodontically treated teeth ◦ Gutta percha removed below the cervical level, bleaching solution is sealed into the pulp chamber ◦ Laser activated bleaching Replacing amalgams for cosmetic purposes or “medical reasons” ◦ ◦ ◦ ◦ ◦ Do the fillings need to be replaced? Can the fillings be replaced with composite? What are the patient’s expectations? Risks vs benefits Informed consent Veneers ◦ Change color, contour or size of tooth ◦ Composite chairside (direct) or lab processed (indirect) – more conservative ◦ Porcelain lab processed 0.3 – 0.7 mm enamel is removed from incisal and/or facial surfaces Extreme discoloration (tetracycline or fluorosis) Strong and stable Contraindicated in bruxers Best on virgin teeth Insufficent tooth structure for veneer Patient bruxes Porcelain fused to metal crowns All-ceramic crowns ◦ More natural ◦ More fragile Healthy patient ◦ Aged 19-25 Repeated episodes of pain from pericornitis No reasonable prospect for erupted properly aligned fully functional 3rds, and desire by patient to avoid future problems ◦ Any age Poor periodontal and/or restorative prognosis and patient is unmotivated Additional guidelines ◦ Younger, healthier patients have an easier surgery, heal faster with more normal bony architecture ◦ When the risk of future caries, periodontal, pericornitis is high – more weight to extraction ◦ When possibility for complications (dry socket, parasthesias, fracture or infection) is high – more weight to not extracting ◦ Reasonable probability that teeth may be needed in future as abutments or to maintain occlusal plane – weight to not extracting Dr. Patrick Palacci Brånemark Osseointegration Center Marseille Diastema closure Removable dentures – can be for any frena with attachment near or on the ridge Removable denture – helps retention Esthetics under FPD Implant placement Results from low grade trauma caused by poor fit of denture flange or body Categorization ◦ Bounded edentulous space – tooth on either side of space ◦ Unbounded edentulous spaces with some teeth remaining – no distal or terminal tooth present ◦ Fully edentulous arch Implant supported prostheses Implant placed in bone and healing cap screwed into place Healing time Abutment placed and impression taken Crown, fixed partial denture or other prosthesis is fabricated for the implant Implant placed in bone at time of extraction = immediate placement Implant, abutment and provisional restoration placed at time of extraction = immediate loading Improved function Preservation of remaining teeth and bone Increased stability Longevity Realistic and esthetic appearance Cost Length of healing period after extraction for non-immediate and non-healing implant ◦ 8 weeks Length of healing period after placement of non-immediate, non-loading implant ◦ 3 months to allow for osteointegration Immediate placement and loading ◦ Healing and osteointegration periods are eliminated Implant should be the primary option Advantages (compared to FPD) Challenges ◦ ◦ ◦ ◦ Stability Longevity Easier cleaning/maintenance Health tooth structure not sacrificed ◦ Esthetic zone placement in three dimensions Contraindications for placement in esthetic zone Inadequate bone density or volume Inadequate buccal-lingual width (perio surgery) Insufficient mesial-distal tooth replacement bone width (ortho) Insufficient interarch space (ortho) Mobility of adjacent teeth Matching the soft tissue contours of adjacent natural teeth to those around the implant ◦ Esthetic periodontal surgery may be needed before at or after implant placement Evaluation for these problems must occur before treatment planning so that patient is aware of all contingencies It is preferred that ALL abutments be implants rather than tooth/implant ◦ Fewer pontics and more retentive units ◦ Prosthesis conveys less stress to surrounding bone More implants needed where heavier occlusal forces are expected ◦ Fewer needed in the anterior ◦ Fewer needed when opposing a removable prosthesis FPD in esthetic zone have same challenges as single unit Two options for non-removable ◦ Hybrid prosthesis Constructed of cast alloy framework with denture teeth and resin – compensates for moderate bone loss and missing soft tissue contours ◦ Metal ceramic restoration Used when there is minimal bone and soft tissue loss Advantages compared to conventional removable complete dentures ◦ ◦ ◦ ◦ ◦ ◦ More stable More retentive Less food entrapment No need for denture relines or denture adjustments Far greater longevity Fixed functions more like natural teeth Disadvantages ◦ Cost – increases with each additional implant or pontic ◦ Time and effort for process and surgery Good for patient with severe bone resorption Complete denture is supported by but not affixed to two or more implants Connect to implants by bar or clips on denture Removed and inserted by patient Advantages ◦ Facial esthetics are enhanced by the support of the labial flanges ◦ Removal at night facilitates daily cleaning ◦ Avoids destructive forces from nocturnal bruxing ◦ Fewer implants needed ◦ Less expensive option Systemic diseases that are contraindications for implant placement ◦ ◦ ◦ ◦ ◦ Poorly controlled diabetes Osteoporosis Radiation therapy to head and neck Immunocompromising conditions Cigarette smoking Assessment of intraoral conditions ◦ Site evaluation for single implant Bone height, width, contour and density Mesial-distal interdental space Interarch space Relationship to anatomic structures Maxillary sinus Mental foramen Mandibular canal Submandibular gland fossa Esthetic zone Lip line Shade, form and alignment of the surrounding teeth Facial gingival and bone architecture Height and density of facial gingiva Assessment of intraoral conditions for implant retained FPD, fixed complete dentures or overdentures All of the previous plus ◦ ◦ ◦ ◦ Lip support Location and size of edentulous areas TMJ evaluation Maxillomandibular relationship, VDO, occlusal plane, arch form and size, occlusal relationships, guidance patterns in excursive movements For decades the best option for bounded edentulous spaces Cast metal or porcelain fused to metal or all porcelain Advantages ◦ Replacement teeth are fixed in place and provide a stable and natural looking alternative to a removable prosthesis ◦ Good esthetics ◦ Good function ◦ Preservation of arch form Disadvantages ◦ Margins, along with poor oral health care increases risk for recurrent decay and periodontal disease ◦ Difficult to keep clean ◦ FPD can compromise the abutment teeth increasing risk for future root canal or tooth loss ◦ Is not indicated if restorative and periodontal condition of abutment teeth are poor Notable indications for fixed partial denture ◦ Bounded edentulous space present and Abutment teeth are heavily restored and are good candidates for full coverage restorations Medical challenges against surgery Financial challenges Patient does not want surgery Forces on the partial denture are transferred to abutment teeth via framework and clasps and to the ridges from the acrylic bases Advantages: ◦ Relatively inexpensive and stable ◦ Provides a measure of function and esthetics Advantages: Disadvantages ◦ Relatively inexpensive and stable ◦ Provides a measure of function and esthetics ◦ ◦ ◦ ◦ Must be removed for cleaning Visible portions of framework and clasps Abutment teeth at risk for caries and periodontal disease Can cause Traumatic ulcers Stomatitis Bone atrophy Epuli formation ◦ Denture is prone to wear, fatigue of clasps, loss of denture teeth, poor fit ◦ Significantly reduced function when compared with natural teeth, FPD or implant retained prosthesis Removable acrylic replacement for teeth and bone lost in an entire dental arch Advantages Disadvantages ◦ Relatively economical ◦ Easy to fabricate and repair ◦ Provide a level of esthetics and function compared to no teeth at all ◦ Lack of denture retention and loss chewing ability Several teeth can be retained in an arch to serve as overdenture abutments Endodontically treated teeth with a capping restoration Disadvantages ◦ Lack of denture retention and loss chewing ability Several teeth can be retained in an arch to serve as overdenture abutments Endodontically treated teeth with a capping restoration (gold or amalgam) Advantages Increases stability and proprioceptive “feel” with chewing Helps to preserve the residual ridge Disadvantages Susceptibility to caries and periodontal disease Implant overdenture is usually better option The objective is to prevent relapse and recurrence of disease More than a “check-up” A personalized plan designed to maintain the patient in optimum oral health Periodic exam, periodontal maintenance, oral hygiene instructions, risk reassessment Throughout examination you have been communicating with the patient, developing trust and rapport With the Tx Plan Presentation, you must use communication skills to reach a consensus with the patient on the final treatment plan If handled well – you will be respected and seen as a professional If handled poorly – you may be perceived as uncertain, lacking confidence, self-serving, arrogant or incompetent. You should NEVER be here You must be prepared to discuss all aspects of the case and be open to any questions or concerns from the patient. 1. Educate the patient about their problems and diagnoses • • • • Start with the chief complaint Use mounted casts, photos, radiographs, drawings, informational pamphlets Use terminology the patient will understand Encourage questions, periodically verify that the patient understands what you have said 2. Discuss treatment options Advantages and disadvantages of each option Short and long-term prognosis for each Outcome if now treatment is provided The importance of patient cooperation on the overall prognosis • • • • • • • • Plaque control Smoking cessation Reducing parafunctional habits Returning for maintenance therapy 3. Cost of services, number of appointments, length of time • In practice you may have staff do most of this Argues that patients must hold four beliefs before they will accept treatment for a particular disease 1. That they are susceptible to the disease 2. That contracting the disease has serious consequences 3. That the disease can be prevented or limited if the patient engages in certain activities or receives treatment 4. That engaging in treatment is preferable to suffering from the disease This comes from a thorough discussion of the patient’s problems The patient must understand and believe in the doctor’s diagnosis before treatment will be accepted The patient must recognize that there is some level of severity to his oral condition Especially important if the patient has no symptoms and has been unaware of the problem Emphasize what may happen if the patient does NOT have the treatment The patient MUST believe that the treatment plan will help solve his problems Spend time discussing prognosis It may be necessary to convince the patient that accepting the treatment plan is better than living with the dental problems. The most common barriers: ◦ Pain ◦ Cost ◦ Time The dentist should always address these three issues Patients prefer to receive information in an interaction in which they do not feel that the dentist is attempting to dominate them When the patient is calm, trustful, and free of anxiety she is more likely to comply with the dentist’s suggestions. When treatment planning is shared with the patient, the patient is more likely to perceive that she has a vested interest in the process and comply with the proposed treatment Questions???